Oklahoma Medicaid TPL Billing Procedures
When submitting all claims, the amount paid by a third party must be entered in the appropriate field on the claim form or electronic transaction. If a third-party payer made payment, an explanation of payment (EOP), explanation of benefits (EOB), or remittance advice (RA) is not required for electronically submitted claims. When a member has other insurance and the primary insurer denies payment for any reason, a copy of the denial such as an EOP, EOB or RA must be attached to the OHCA claim or the claim will be denied.
If an EOP, EOB or RA cannot be obtained, attach to the claim a statement copy or correspondence from the third-party carrier. When billing the OHCA for the difference between the amount billed and the primary insurer’s payment, the OHCA pays the provider the difference, up to the OHCA allowable charge.
If the primary insurer payment is equal to or greater than the allowable charge, no payment is made by the OHCA. In this instance, the provider is not required to send the claim to the OHCA for processing. Providers cannot bill members for any balance.
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